91. Hypertensive Disorders of Pregnancy & Future Health Considerations with the Heart Health Matters Team
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This week’s episode is joined by Dr. Karen Fleming, the Chief of Family Medicine at Sunnybrook Health Science Center and Karen Fung, a Registered Dietician and certified diabetes educator at the Sunnybrook Family Practice. Dr Fleming and Karen Fung are part of the Heart Health Matters team, whose aim is to empower people diagnosed with Hypertensive Disorders of Pregnancy (HDP) to manage future cardiovascular health.
Tune in as we discuss hypertensive disorders, high blood pressure in pregnancy as well as gestational diabetes. We discuss the long-term impacts of these conditions postpartum and how to reduce risk of cardiovascular disease.
Dr Fleming and Karen Fung share how they work to provide a holistic, community approach in their care plan for their patients and how they seek to provide information to empower individuals for better health. Their free virtual workshop Post-Pregnancy Heart Health offers a holistic community approach to addressing postpartum health. Their workshop features different healthcare professionals, including a physician, a dietician, a social worker to discuss mental health, and a nurse with health coaching expertise. Check out more here: About the Heart Health Matters team.
Sign up for the next Post-Pregnancy Hearth Health workshop:
—https://www.hearthealthmatters.ca/
Connect with Surabhi:
Website: https://www.thepassionatephysio.ca
✨This episode is sponsored by Embodia https://www.embodiaapp.com/ - use code momstrength to save $20 off your first month’s Tier 3 membership.
✨Click here to learn more about How I use Embodia as a Pelvic Physiotherapist!
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Surabhi: [00:00:00] Hello everyone and welcome back to another episode of Mom Strength. This is your host, Sobi Veatch, and I'm really excited to have on two special guests today from Heart Health Matters, Dr. Karen Fleming and Karen Fung. So they are both Karen's. Karen, Karen F. So I'm gonna, um. Call Dr. Fleming, Dr. Fleming, and we're gonna call Karen Fung, Karen, um, just for ease of, uh, communication.
So welcome to my podcast. Thank you both for being here. Uh, I would love to begin with asking you, um, just to briefly introduce yourselves and, um, you know, what your mission is at Heart Health Matters.
Dr. Fleming: I am happy to start. Um, this is Dr. Fleming here. I'm the Chief of Family Medicine at, uh, Sunnybrook Health Science Center.
I've also been, uh, involved in delivering babies [00:01:00] and following, uh, families across the lifespan for at least the past 25 years. Um, our goal of our, our website and our education programs is to build awareness. Of, uh, what happens in pregnancy and its impact on, uh, the future health of both the child as well as for the, the mother, the birthing parent.
Surabhi: That's something that I think a lot of people may not be aware is how it also impacts the birthing child or the the child as well as the mother. Um, and that. These issues that happen in pregnancy may also persist postpartum or increase, um, prevalence of disorders postpartum. Right. Um, can you and Dr. Or, um, Dr.
Fleming, thank you for the intro. How about, uh, Karen, would you like to introduce yourself as well?
Karen Fungaren: Sure. I'm Karen. I'm, uh, I'm Karen Bun. I'm the dietician, registered dietician and [00:02:00] certified diabetes educator at the Sunnybrook Family Practice. Uh, for Dr. Fleming. I'm also part of Eck, which is the diabetes education side of things at Sunnybrook.
And yeah, I've run a lot of sessions with, um. Lots of different age populations with regards to, you know, food, nutrition and how it can impact our health and what to do. And yeah, I've been on this project helping with, uh, uh, women with hypertensive disorders of pregnancy for a little bit and also on the diabetes side.
Um, we've been running gestational diabetes postpartum classes for many years.
Surabhi: Amazing. Thank you. Both, both very, very valuable and important work. Um, so let's get started. I would love to hear about what are the major hypertensive disorders, um, in pregnancy, and how prevalent are they? Dr. Fleming. Yeah.
Dr. Fleming: Yeah.
I was gonna take that question. So, uh, about 7% of [00:03:00] uh, uh, pregnant people in Canada will develop a hypertensive disorder of pregnancy. So this may be someone who has preexisting, uh, high blood pressure prior to pregnancy, but we define pregnancy blood pressure. So someone who's not had any problems with their blood pressure prior to that time.
If they develop a high blood pressure after 20 weeks of pregnancy, so you can have gestational hypertension, which is blood pressure after 20 weeks of pregnancy, that is by itself, if you will, and continues on. And, uh, you go through the pregnancy, things are managed fine and you end up delivering, and that's the gestational hypertension you can also develop.
Uh, hypertension with other features. And you may have heard people talk about preeclampsia. Uh, and that is a condition that has high blood pressure with it, but also it has [00:04:00] impacts to other parts of the body. So people will have some vision, could have visual changes, they could have, um, chest pain, they could have protein in their urine.
And that is, uh, that is more. Severe usually than the hypertension. In pregnancy, you can also have something called eclampsia, which is the preeclampsia with seizures. So seizures would bring you to a diagnosis of eclampsia that is much less common because we've got medicines that we use and, uh, to reduce that, to reduce the risk of seizures.
But we are watching, uh, watching for that. So it's a collection of. Health issues that, uh, have their first manifestation after 20 weeks of pregnancy. So there are some risk factors that would place people at risk of developing, uh, hypertension or, uh, [00:05:00] or preeclampsia. So first off, if you have high blood pressure prior to pregnancy, you are more at risk of, uh, uh, developing preeclampsia over the course of the pregnancy
Surabhi: and what would be classified as high blood pressure.
Dr. Fleming: So blood pressure over one 40 over 90 on two on two occasions. Um, and this needs to be monitored. Uh, you wanna test the, that, uh, that's not just one off reading, but it is, uh, a reading that you.
Surabhi: And this is something that most people are getting tested during their monitoring, their routine monitoring with their practitioners.
So, um, this is really helpful information. Um, what if somebody naturally has low blood pressure, but then it rises up in pregnancy still below that one 40 over 90? Would they still be considered to have high blood pressure if it rises above a certain amount? Or is it the 1 40 90 That's the, um, kind of the [00:06:00] gold standard?
Dr. Fleming: So that's a great question and while we'll take that into consideration, the diagnosis would be, uh, a specific numbers. Okay. Good to know. See if someone has it. We might be taking more notice.
Surabhi: Okay. 'cause a lot of my patients have low blood pressure in pregnancy and you know, if it, there's a sudden spike, it's about, you know, where's the, the ma majority of the concern.
So that's good to know. It's the, the absolute numbers. Um, okay. Um, and then what are other risk factors? So you mentioned high blood pressure in pregnancy, or sorry, prior to pregnancy is a risk factor. Um, what are some other things that might increase someone's risk?
Dr. Fleming: So if someone has a history of kidney disease.
Um, if someone has a history of, uh, some of the arthritic conditions like lupus or rheumatoid arthritis or immune conditions, family history. So family history is an important one. [00:07:00] And so it's always great to know what your sister or your mother or your grandmother, if they had anything happen exciting in their pregnancy.
So if they had. Uh, diabetes in their pregnancy if they had high blood pressure in their pregnancy. This gives helpful information for, for you to know if that's something that you are going to be at risk for, which is important. 'cause there are things that we can do that can reduce the, the risk of developing, uh, both gestational diabetes and the gestational hypertension preeclampsia.
Surabhi: And is, um. Is, is kidney disease in particular, does that include kidney stones or is that, uh, you know, what kind of conditions fall under that?
Dr. Fleming: So it wouldn't be kidney stones, it would be people with underlying disorders of their kidney. That could be things like something called glomerulonephritis People would know if they, if they haven't, because they will [00:08:00] usually have been doing follow up with their primary care provider or seeing a nephrologist.
Um, so that would've been, that's a group that probably is already aware of
Surabhi: Already aware of. Okay. That's good to know. Um, 'cause I think some, some people just, every symptom in pregnancy is so new, you know, from the nausea to the fatigue. And so sometimes people don't know, is this a normal change in pregnancy or is this something that I need to be alarmed about?
And so. When people understand, okay, high blood pressure, that's a very simple test. And they're doing that routinely with their primary care provider or their, you know, ob, GYN, your, their midwife. Um, but the other things to consider, you know, kidney disease, it's likely diagnosed prior. Right. Um, that's, that's good.
Any other risk factors to be a aware of? Is age one, like it is for everything else it seems.
Dr. Fleming: Uh, yes it is. Yes, it's increased age and lower, uh, lower age is also a risk factor. Oh, so [00:09:00]
Surabhi: what would be considered lower then?
Dr. Fleming: So I, you know, if you're basically, we're not seeing that much, but speed definitely under, you know, if you're seeing someone under 18 or uh, over 40, the rest is more significant.
Surabhi: Okay. Okay. Um. Is there something people can do to, are, are there any other risk factors before we kind of move, um, to the next question?
Dr. Fleming: I think we've covered, uh, a lot of 'em. So things that we, we know that physical activity is, uh, great medicine, whether you are pregnant or you are not pregnant. And we have good guidelines from, uh, 2019 on physical activity in pregnancy, and a lot of data that suggests that physical activity in pregnancy, uh, can really help to reduce the risk of gestational diabetes as well as high blood pressure in pregnancy.
And that this [00:10:00] can be started, uh, ideally before pregnancy, but could be started, uh, in early pregnancy as well. We know that the guidelines are that 150 minutes, uh, a week, you can start, uh, slow and gradually increase aiming for sort of three days of the week. Although physical activity all days of the week is, is good and it's moderate intensity .
Activities. So walking is great if people are already, uh, running, that is something that they could continue. Swimming is good. Stationary cycling. You wanna be mindful of not bumping the bump. And so, you know, uh, downhill skiing might not be what you want.
Surabhi: Surfing, downhill skiing. Maybe avoid those. Maybe
Dr. Fleming: avoid, avoid those.
Keep diving we can, doesn't protect the, uh, the baby from decompression. So. Yeah. Um, and there are good resources that are available for that, but there's really significant, uh, benefit of, [00:11:00] uh, of reducing risk for, for the hypertensive disorders of pregnancy.
Surabhi: And that makes me really happy to hear, because that's what, as a pelvic physiotherapist, I help people with movement and getting active through pregnancy because, you know, many people are limited by back pain, si pain, pubic pain, you know, fatigue and.
One of my key jobs is not just symptom management is, but is to also prepare their bodies for the pregnancy and birth and postpartum. And so strength training, movement, cardiovascular exercise is all part of it. So for anyone listening who's like, I wanna be active, but things hurt, you know, there is, there are ways to support you to being active, which also helps you to reduce your risk for, um, these hypertensive disorders.
So there's multiple benefits for being active, right?
Dr. Fleming: Yes, it's, I mean, the, the data is pretty compelling, um, and pelvic floor. Is, uh, also in the guidelines of the importance of yes. Uh, pelvic, pelvic
Surabhi: floor [00:12:00] training.
Dr. Fleming: Yeah, absolutely. So just
Karen Fungaren: a, a few more, uh, risk factors. Um, it would be things like multiple gestation, um, that's a higher risk factor too, right?
Dr. Fleming, um, you've had twins, uh, triplets, triple, and then smoking is sort of the other blaring one that, you know,
Surabhi: smoking pre, pre-pregnancy or during both. Yes. How about alcohol?
Karen Fungaren: I'm not sure if there's a lot of, um. I guess evidence around that, but
Dr. Fleming: literature on alcohol, particularly with the hypertensive disorders of pregnancy. Yeah. But we do feel that that's not something that we would, we don't want to be, we want to reduce and not use alcohol in pregnancy. So,
Surabhi: yeah. And, and I was thinking more even prior to pregnancy, I was wondering if there's any literature because we know about smoking, but, um, I feel like nowadays there's more, it's more normalized to drink alcohol [00:13:00] versus smoke.
Um, I mean. Now though, there's vaping and all these other things that are, that have come about. So, um, does that all fall under smoking? You know, vaping included, uh, in terms of risk,
Dr. Fleming: would want to reduce, uh, vaping, all of those things. Yeah. Yeah. So any, any substance use, uh, we would , want to tackle that as a, a separate and important issue.
Surabhi: Yeah. Yeah. Um, and does it, does it increase the risk factor if. You've had multiple births. Like if you, if it's your fourth child, your fifth child, does the risk go up or not really?
Dr. Fleming: It's more, excuse me. It's more common in your first pregnancy. Ah,
Surabhi: okay.
Dr. Fleming: And if it's happened once before, like most things, uh, in pregnancy, it's more likely to happen again.
But it's. The first pregnancy is, uh, is the time that people are most at risk.
Surabhi: Most at risk. And is there any, um, information on the [00:14:00] male, like the sperm quality, does that influence risk? Um, because I know there's more research coming out now about sperm quality and it impacting, you know, placenta health or, you know, the health of the, the fetus.
Um, is there any information about how that might impact things?
Dr. Fleming: To the best of my knowledge, I'm not aware of anything to do with the quality of the sperm and the, and the, and the fetus, so okay. Timing between pregnancies is, is a potential risk.
Surabhi: Okay.
Dr. Fleming: Um, and length of time, but specific, no, not, uh, not aware of that.
Get another risk factor that elevated. BMI. So entering into pregnancy. At, um, at, um, with a, with a healthy BMI is would be ideal. And also looking at weight gain over the cross, uh, across the pregnancy is also important, [00:15:00] which I think Karen could speak to, uh, much more eloquently than I can because I have the luxury of referring to having a dietician who works with me, uh, here at, uh, here at Sunnybrook.
Surabhi: So what would be, Karen, what would be a healthy weight gain for a pregnancy?
Karen Fungaren: I believe it is 20 up to 23 pounds, but um, it does depend on where you start. So with the higher BMI that you start the, you know, a little bit less of a weight gain that we're ideally looking for, for supporting your pregnancy and the lower your weight. Um, sort of similar idea, um. But I, I do wanna preface that BMI is a crude calculation of health, and it is not the only thing that we should be looking at.
That is why we support, you know, your, um, uh, prenatal and, and antenatal, uh, appointments with things like blood pressure, with [00:16:00] things like blood work and sort of just like your overall potentially nutrition that you may not talk about with your OB, GYYN and may not talk about with your midwife, um, but are.
Sort of important factors as well in physical activity. So, uh, although it was one of the things that, you know, is a risk factor, it's not the only one and should not be, you know, we're very careful about what we talk about in terms of weight because we're not, we're understanding that we're not in full control of our weight, just like.
We're not in full control of our blood pressure. You don't wake up saying, I would like my blood pressure Yes. To be 120 over 80. Right? Yeah. So, mm-hmm.
Surabhi: And do you notice, and it, the thing with BMI too, some people have a lot of, they have a big frame or a lot of muscle mass, and their BMI can show up as elevated, but they're actually healthier than the person who's, you know, maybe smaller frame, but.
More visceral fat or, you know, there's so many factors to consider. So I like that you look at kind of that big picture. Um, is there are, do you find that there are ways to support, um, people who, or [00:17:00] I, I guess going back to blood work, what you just mentioned, do you recommend people getting certain things tested in terms of their blood work?
Um, what are key things to look for?
Dr. Fleming: So we have a lot of blood work that's quite standard for pregnancy. Um, and anyone who's been through pregnancy realizes that we do a ton of, uh, in that first, uh, you know, three to four months of pregnancy. We, we, we screen people again for their, uh, iron levels and. Check for, do a, a test for the diabetes of pregnancy between 24 and 28 weeks.
Um, in pregnancy, there's not specific things that we would do preventative wise, but we do. If someone has, uh, has symptoms or is, or the blood pressure changes, then that will lead to us doing some different blood work. [00:18:00] The, uh, post having a pregnancy that was complicated by, uh, high blood pressure for a long time now in the Canadian, uh, guidelines for, uh, who gets checked for the cholesterol.
The hypertensive disorders of pregnancy has been in those guidelines since 2016. But while they're in the guidelines, we know from the literature that not everyone. Is, uh, is aware of that either the people themselves or necessarily the primary care providers who may or may not even know that, that there was an issue in the pregnancy?
Exactly. Yeah. Um, midwives and obstetricians will no longer be caring for people after they've, uh, finished their, uh, pregnancy and their postpartum period. So it is after that time, there are coming new guidelines that are going to bring all these things [00:19:00] together so that there are strong recommendations that for what should be done, uh, after, after pregnancy.
So what should we be doing at six months after pregnancy? What should we be doing it at one year? Which I think will be very helpful to provide a roadmap for people themselves, but also for the primary care providers. And hoping that we can set up good communication from the hospital to the, to back into community care or from delivery back to ongoing primary care.
We know in healthcare that anytime people are, um. There's transitions in care that things can sometimes fall between the cracks and, yeah, uh, we see, uh, see things that we maybe didn't have the opportunity to look after because we weren't, weren't aware. So this is where pathways become important. We're having conversations with people like yourself and trying to get the [00:20:00] word out because, yeah.
Uh, knowledge is power and it's really important for people to know what their individual risks are and what they can do to change their, their future risk. Because just because someone's at risk for something doesn't mean it's going to happen. You can have the power to make some of those changes.
Surabhi: That's empowering because, you know, sometimes people have a bad family history or, you know, maybe they have precursors, you know, high BMI or um, high blood pressure to begin with. But it sounds like there's things they can still do regardless of, you know, what they start, what, how they're starting out. Um, and you know, it's interesting, a lot of my patients postpartum, even if they had, let's say low iron and they needed, uh, supplementation or even an infusion.
Postpartum. I'm like, okay, have you had your blood work checked postpartum? Almost always it's, no. It's almost like they're cut off from care as soon as they're past that six week mark and they themselves don't even know or don't think to go get things retested to [00:21:00] see where they're at now and. In particular, if they're breastfeeding or chest feeding, you know, or pumping, they're still, you know, nourishing their baby.
And it's like you still need those nutrients for yourself and for your own body to heal and then also to nourish your baby. So, um, there's a lot of, you know, even, I don't know what the guideline is, how, how long do you wait to get your blood work checked postpartum or what the recommendations are. I mostly just encourage people to go see their primary care providers or doctors to get that follow up.
Um. And so if somebody did have high blood pressure in pregnancy or if they did have preeclampsia, what would be the postpartum recommendations for support? I.
Dr. Fleming: For support. So if someone's been diagnosed with high blood pressure in the pregnancy or when they go to be discharged, they, they need to be seen at the three to five days after [00:22:00] they've, uh, been discharged from the hospital.
The reason for that is that we can see a change with the fluid chests where blood pressure can climb. So if they're seeing, if you're seeing a midwife or you're seeing a family doctor, they may do that visit concurrently or if you are, if you're not, then either your primary care provider should see you or your obstetrician, but someone should, um, should see you in that timeframe.
People really often know that they need to bring the baby in, but not necessarily that there's, there's something something
Surabhi: for them. Yeah. '
Dr. Fleming: cause we sort of, you know, I'm, I'm not pregnant anymore, so it's done right. It's, and it is the beginning of the, it is the beginning, but it's, we do need to be mindful of, of that, because.
The blood pressure can go up with those GS in, in fluid. So blood pressure definitely needs to be, be taken and we don't want to [00:23:00] have people ha having to come to the me or otherwise when, when we could, um, manage them and do the detective early. So I think that's a key message is that if it's not over at discharge, you need to have that, have that follow up and, and follow and having that information.
Travel with you to back to your primary care provider is really key and critical so that they can follow you and you can work together for future health.
Surabhi: That's a really important message. Um, really, really important I think if people know that, okay, three to five days postpartum, not, is it the appointments are not just for your baby, but also for yourself.
Have your own blood pressure checked. Um, would it be blood work then, or mostly blood pressure checking At that point
Dr. Fleming: we would. Blood pressure checking and it depends. On all the other, all the other
Surabhi: things you may
Dr. Fleming: take, you may need liver. Maybe someone [00:24:00] had a lot of blood loss of the delivery. Yeah.
There's multiple kind of reasons why they're, that's certainly key having that, uh, that that checked done.
Surabhi: And one thing to note is postpartum. I mean, there's so much sleep deprivation and stress and it's such a big transition. And aren't those also risk factors for high blood pressure on, you know, individually like, you know, stress and um, and then you com compound that with somebody who has maybe a history of high blood pressure and pregnancy.
So to me that's even more important to get checked postpartum because now if anything, your stress levels are gonna be higher, um, in those first few weeks postpartum, when. Yeah, everything is just draining and exhausting and there's a baby crying and you're trying to figure things out, right?
Dr. Fleming: It is a very busy time, and it's a hard time to prioritize, uh, you know, parents' health and, and baby's health and, and sleep.
Sleep deprivation is, is real. So we know that, uh, [00:25:00] we know that it, it's, you're gonna go without some sleep at the start. And sleep is, is important for, for future health.
Karen Fungaren: And that's, that's one of the messages that we like to give new moms especially, but even moms of a second, third child, is that, you know, they need to consider their health and their status immediately post pregnancy.
Maybe that six week post-pregnancy, and then after that it really fizzles out. But really, a, a, a key time is also that six month post-pregnancy, especially if you've had any type of, um, conditions during the pregnancy, diabetes, hypertension, preeclampsia, um. And that's where I think when you are dealing with sleep deprivation, uh, learning about a new baby, and you're going to see your family doctor or your primary care provider that you forget to mention, oh, by the way, I had this thing happen.
I had to stay in the hospital for X amount of days. And you know, one of the messaging that we like to remind everybody, [00:26:00] whether. They're, you know, 60 years old, but then they're having, you know, um, a neighbor that is pregnant is to remind everyone, like, don't forget about your health, uh, aside from the baby visit.
Surabhi: Yeah. That's so important. And I think partners too. If, if the, you know, birthing person has a partner or kinda support system, maybe outsourcing some of that to them so that. It's so hard in your brain to keep track of everything. And even as a healthcare provider myself, I've been to the doctor before where I've been like, how did I forget to ask that one question?
You know, you just, it just escapes your mind. Or when I'm doing a postpartum visit with a patient and they're informing me how their birth went, they'll completely forget the fact that, you know, they had. Uh, third degree terror. Like, if I'm not asking specifically, it's just escapes their mind, right? And so I think it's important to be proactive and expect that you will forget these things.
So either write it down, have somebody with you that they can remind you. I love the idea of even if you have a neighbor, you know, checking in on each other, that community [00:27:00] support that we often forget about is, is so, so important. Um. One thing I was wondering, does it, does the risk go up whether you've had a c-section or vaginal birth in terms of the postpartum, you know, risk of high blood pressure preeclampsia or any hypertensive disorders?
Dr. Fleming: Uh, no. The mechanism of the birth isn't going to impact that. So, or
Surabhi: like induction, all the, all the interventions, they don't really play a role necessarily in the postpartum, um, kind of
Dr. Fleming: in your postpartum risk of developing. Higher blood pressure or running into issues postpartum? N no. Okay. We do know that if someone has early onset preeclampsia, so someone by early onset, I mean that if they had, say they were 28 weeks pregnant till they, um, if the risk, the risk to the future is greater when it presents itself earlier.
Earlier, okay. Is [00:28:00] different than the. If it happens later or a term. So
Surabhi: what, what are the signs of preeclampsia? So high blood pressure, uh, what are other signs for people to look out for in pregnancy?
Dr. Fleming: So, so regular times that we, we give to, uh, pregnant people, and if baby's not moving, we want to, that's, you know, fetal activity is, is important.
Headache, blurred vision. Um. Somebody who has chest pain or they're having difficulty with their breathing, or they've got pain in the, their right upper quadrant, uh, these are, or they're having sort of bleeding from their, their nose or their thumbs. There's, if you think about, it's a whole system, the preeclampsia can affect our whole system, so.
It's, we're kind of starting head to toe at, uh, at where things, things could, um, could be. And so we [00:29:00] like to think that this is anticipatory guidance that, uh, people will be getting at their, at their appointments. And not to say that every headache is, uh, a headache from, uh,
Surabhi: preeclampsia
Dr. Fleming: pressure, not at all.
Um. Is just being mindful of the, of the cluster of, uh, cluster of symptoms and when to come in having a low threshold for being checked.
Surabhi: And this is, this is the tricky part because so many of those symptoms can also be mean, you know, heartburn or, uh, you know, shortness of breath 'cause your baby's shoving up into your ribs and you know, there's so, and even low iron, right?
So that can also present as some of that breathlessness. So it's. I think I like what you said about the cluster, so it's not just one symptom in isolation, it's usually, it sounds like it's usually a cluster of symptoms, um, in combination with, you know, if the person is just having any, has any concerns or worries, they can al always go back to their provider and have them, um, screen for it.
[00:30:00] Is there a certain, um, like aspirin or something that people are recommended to take as a medication if they have high blood pressure in pregnancy?
Dr. Fleming: So you are talking about aspirin for prevention. So, ah, so yes, we, we know that, uh, there's good data that using, starting someone with a, either a past history or some, a family history of some, a risk factor that places them at risk for having a pregnancy to a risk for hypertensive disorder, pregnancy that's starting, um, aspirin between.
12 to 16 weeks is, has good evidence for reducing, uh, likelihood of developing particularly early onset, uh, preeclampsia.
Surabhi: Preeclampsia.
Dr. Fleming: So that's two baby aspirin or 162 milligrams here in, in here in Canada. And you would, uh, start that ideally taking it at that time. [00:31:00] If we know that having a diet that, again, this is probably in, uh, Karen's, uh, world rather than mine, but, uh, wanting to make sure that, that your diet is, uh, is complete with calcium, and if it's not, then a supplementation that if has been associated with a reject too, so
Surabhi: calcium, I'd love to learn more about that.
Yeah. Karen, if you could speak on that.
Karen Fungaren: In terms of calcium, like sources or,
Surabhi: yeah. So, um, I guess how does calcium, how does calcium impact, um, the blood pressure? Maybe understanding like the role of calcium and what are some common sources that people can, um. Get calcium.
Dr. Fleming: So you wouldn't use calcium if you're, if you're getting enough calcium in your diet, you wouldn't supplement for a reduction Okay.
Of risk. But if someone has a, a diet that is low in calcium, then ensuring that they [00:32:00] are getting a gram, uh, a a day is important. And that's when being able to provide resources or, um, having the luxury of being able to. Have them speak with a dietician who can talk about the different, where their sources
Surabhi: Yeah.
Dr. Fleming: What are the choices, because it can be hard to know and
Surabhi: so, so, and the regular prenatal would not cover that. One gram of calcium. I guess it wouldn't be enough in a prenatal source. It's, it's,
Karen Fungaren: uh, most prenatals don't have a full gram of calcium. Um, and I would say that the populations at risk are people who are vegetarian or vegan.
Or they have strong sensitivities to dairy because those are still the best sources of calcium. Um, because also calcium from our plant sources are difficult to absorb. The bioavailability is quite low. Those are the folks who were a bit more concerned. So if you consume zero dairy [00:33:00] and potentially you are vegetarian or vegan, you are probably not getting enough despite taking a prenatal.
Surabhi: And I really, um. This is information that I feel like not everybody has, right? This is as a lifelong vegetarian. Did not know that, you know, uh, with, with increasing the risk of even just the link with higher blood pressure and it's not something that's widely known. So I think that's important. Even if we have patients that are vegetarian or vegan or completely dairy free.
I'm seeing that more and more now. A lot of people are going dairy free and so, um, our other milk soy milk, for example, is it fortified with calcium or is it still not as bioavailable? 'cause it's not, not from a.
Karen Fungaren: Yes, I would say that the dairy alternatives are quite good. Um, the main component that. Lowers the bioavailability and the absorption of calcium is fiber.
So those dairy alternatives don't have a ton of fiber, [00:34:00] and so it's actually fine to have those as a source. So your soy milk, oat milk, and almond milks are frequently and almost across the board, at least in Ontario grocery stores, uh, fortified with calcium, you are looking for that 30%, uh, at least 25% of your daily value.
Um. Uh, per one cup that would be equivalent to a cup of regular cow milk in terms of calcium.
Surabhi: That's really, really good to know. 'cause at least then people have options and they're not just, um, yeah. You know, stuck with, 'cause sometimes supplements people, um, get more nauseous when they take more supplements in pregnancy, especially if they have a lot of nausea.
Um, I don't know about calcium supplementation in particular, but I know sometimes when people take iron it can constipate them and then worsen their pelvic floor symptoms and pain. So, um, that's really good to know that there's other options out there. And speaking to a registered. Tissue would probably be the best if they're, if you have access to one 'cause then you get customized information, you know, for you.[00:35:00]
Um, can you tell me about, you mentioned gestational diabetes. Does this count as one of the hypertensive disorders or is this something that's separate?
Dr. Fleming: Separate? It's, it's,
Surabhi: um, because it's more blood sugar, but I wasn't sure if it kind of, the risks go hand in hand.
Dr. Fleming: So you are, if you've had a hypertensive disorder of pregnancy, you are more at risk of developing type two diabetes in your future.
Surabhi: Wow.
Dr. Fleming: They are separate, uh, conditions. Okay. They may, you may have both together, but they're not, uh, they're not related per se other than on potentially shared risk factors.
Karen Fungaren: Are there?
Surabhi: Um, yeah,
Karen Fungaren: they have more, um. Postpartum impact. So if you've had gestational diabetes, you may be at higher risk for having type two diabetes in the future and or cardiovascular [00:36:00] risks in the future. And then same thing with hypertensive disorders. In pregnancy, you may have higher risk for developing diabetes in the future and or hypertension and other cardiovascular risks in the future.
Surabhi: What, what are the risks to the baby, if the, or is, are there risks to baby if the mother has hypertension in pregnancy or high blood pressure?
Dr. Fleming: Do you want to take the, Karen, do you wanna take the diabetes piece since you run the six month, uh, postpartum class for that?
Karen Fungaren: Sure. So if we're talking about gestational diabetes, so diabetes in pregnancy, then the baby. Well, we, because we're doing a fairly good job at identifying the moms who are having this, uh, we usually keep, uh, our, our moms in a really good spot in terms of blood sugar.
They're often referred to a diabetes clinic or a gestational diabetes clinic, and I should say, to manage this. And so we are sort of aiming [00:37:00] for, in providing a normal glycemia type of environment for baby. And typically speaking this. Lowers the risk. But of course if we've had trouble with that, then it can increase the risk for baby for, um, I guess.
And it's partly in the ge um, in the genetics, that baby can have a higher risk for, for example, type two diabetes. Um, immediately I think after delivery there is a concern if we have had gestational diabetes and they're closely monitored, so we're worried that baby might be hypoglycemic. So. But it, there's a lot of careful monitoring at that time.
Um, probably an extra nights hospital stay in Ontario or just closer monitoring. So a lot of pokes, um, for the baby's foot to check the blood sugar there.
Surabhi: Okay. Um, and are there, is it ever missed in people where they have gestational diabetes but the test doesn't catch it? Or is the test pretty, pretty good at catching, uh, and screening for it?
Karen Fungaren: I think, [00:38:00] uh, if you're seeing a healthcare provider during your pregnancy and you're going for that, I think now providers are, are suggesting anywhere between 24 to kind of 28 week to do your sugar test. Um, it's usually caught. Um, some providers are seeing. And Karen and Dr. Fleming, maybe you can verify to even pushing the envelope a little bit more to test at the 28 weeks can make sure we don't miss it.
'cause if something presents at 24, sorry. If something doesn't present at 24 weeks, but we had checked at that time, but ended up happening at 28 weeks. Sometimes we miss it. But that's, I think that's the, the window in general that we're testing.
Dr. Fleming: We have, we have good screening, uh, tests for, you know, we do the initial screen and then if someone screens positive, we can do a definitive test. So, uh, overall we're doing a pretty good job of capturing the, uh, those who are at risk for, [00:39:00] for developing the gestational diabetes and treating them. The world of the hypertensive disorders of pregnancy, uh, perhaps not as good a job, particularly after the, uh, after someone has delivered because it's just not well known, whereas it is pretty well known that if you had diabetes in pregnancy.
Then you are more likely to be at risk for developing diabetes in your future. So what the literature tells us is that both, uh, physicians and um, people themselves are more aware of that risk and are not as aware. If they have high blood pressure in pregnancy, that that, is that also a risk for their future, future health?
It's so that is part of the, the knowledge gap that we're Yeah. Trying to, what you're trying to change, overcome, and, and change. So it's, uh. [00:40:00] So we're very happy to be able to share that information because we know that preventative care is, and there are things that can be done so, so important to have the opportunity to lower your risk and impact your next pregnancy as well and future health.
Surabhi: Exactly. If people wanna have a second or subsequent baby and they're already impacted with their first, it, it sounds like it doesn't necessarily mean that they cannot have another child. They just have to be more careful with monitoring and, um, likely get back to being active. So this is where, you know, um, I know fitness isn't always the number one goal.
Postpartum. It doesn't have to look like being in a gym, you know, five days a week. You can get movement in other ways. And this is what, um, people like me, you know, this is what I help people, is to get. Strength training, mobility, whatever it is that they wanna do, um, get it in, in a way that actually fits their lifestyle, um, postpartum.
One question I have is, do I know that in hypertension in particular, or [00:41:00] heart disease in particular, um, is there some ethnicities are more impacted by that? So would, for example, south Asians are at elevated risk of heart disease? Right? So high blood pressure is also one of the things, um. Is, do you find that there is more routine screening required for certain ethnicities when they're pregnant or even postpartum follow up?
Is, is this something people need to be aware of that if they have higher risks?
Dr. Fleming: So we do know that, uh, black women are more at risk of developing high blood pressure and pregnancy, for instance. So there are ethnic, uh, some groups that are more at risk than than others. So management and screening is, is similar, but we the same.
The risk is, uh, the risk is is greater.
Surabhi: So if somebody's listening and you know, they're a black Canadian and they're like, you know what, I maybe need to be. Extra careful just to [00:42:00] be screened. Right. Even if they don't necessarily have a family history. Um, the aspirin recommendation, I'm curious about, because I'm hearing more about this now.
Who would be the person who would recommend it? Would it be the family doctor or would it be the ob GYN or the midwife? Like who, where, who would play a role in recommending that the person take that preventively?
Dr. Fleming: It could be all of the above. There are guidelines that, uh, for when to start it. And, and so if, uh, say you were planning for your pregnancy with your family physician, then they would talk with you about it and tell you when to start it.
You may or may not see the provider who's gonna care for you in pregnancy until after that first trimester.
Surabhi: True. Yeah. You might not see them till 12 weeks. And then it's kind of like, yeah,
Dr. Fleming: so it could be the midwife, it could be the family doctor before. It could be your nurse practitioner, before it could be [00:43:00] your ob gyn.
When you come to that, come to that visit. Um, so it could happen in all of those, all of those areas. And that's part of what we do at the postpartum visit as well, is that we will remind people, but knowing that there's a lot that we cover at the six week postpartum visit, so it may not be top of mind. Uh.
You know, two years from, two years from, yeah. So, yeah. Um, and it's really important for us to do deliveries, to share that information back with both the person who is pregnant as well as with their, who's gonna care for them, uh, going forwards. Right. We don't wanna Yeah. Miss providing that, that information.
Surabhi: Because there is a bit, it is all a bit of a blur, you know, like the whole labor, the birth, the whole, you know, week around that. And so I can imagine if information is given then also to make sure [00:44:00] that it's given to the people caring for that person so that it's not, you know, they don't fall through the cracks.
Right. Um, it's one, one of the things that, uh, I'm curious about is also mental health and how that might impact, um. Does it go up? You know, are these conditions more common in people who may be having mental health, uh, challenges or, um, we did briefly talk about stress, but things like depression or, um, perinatal anxiety, do those also play a role?
Dr. Fleming: So we know that, um, the people who've had, like all people postpartum, that mental health and physical health are both very, very important. And that, uh, if you had a, a complicated pregnancy or whether that's, whatever that complication may be, but it may be that you had early onset preeclampsia and you had to [00:45:00] deliver early, and it wasn't what you anticipated or, or expected, uh, is.
Understandable. And we see that people are, it is a risk factor for, uh, um, anxiety, depressed mood. And depending on the, the nature of the, what happens could be more so. So mental health supports is important for all people, uh, postpartum. Is one of the reasons that we involved our dietician, our health coaching, and also our social worker to participate in the, the workshop because it is such a key area of need in the postpartum period.
So I really
Surabhi: like that you have, uh, like a holistic view on, on this because it's, I think, so often in the. Perinatal space. It's like you go to this specialist [00:46:00] to do this and you go to this specialist and they're not always communicating and they're not always kind of coming together. So I, I really think that having all of you on the same team, kind of communi communicating together and offering a workshop, um, is really helpful.
Can you tell me about your next workshop or, uh, what your workshops are like? How do people sign up? 'cause I will, I'm happy to share that information, uh, with my audience and, um, with my patients as well.
Dr. Fleming: So people can sign up for the, for the workshops through our, through our website. Okay. And there's a QR code and they can, uh, and they can sign up for the workshop.
We're running them every two to three months. It is an opportunity to. Uh, it is an interprofessional group. So we have, uh, Karen will be there as a dietician. I facilitate as a, a family doctor who does obstetrics. We've got a, um, a nurse with, uh, health coaching [00:47:00] expertise. We have, um, our social worker doing, um, to discuss mental health.
So we, it really is more of a holistic, uh, holistic approach. And, uh, talking about all the different areas where you dimensions that around education and empowerment for, for your future health. And so I think that's really part of the, the good piece and of this and your resources are given out afterwards, so you're not
Surabhi: amazing
Dr. Fleming: one and done, but you also, there are some resources that are available.
To you afterwards, depending, and we will send a letter to your family doctor or nurse practitioner afterwards so that they know what we've talked about. They've known what sort of we recommend going forward and what potential resources there are in the community. So Karen [00:48:00] spoke to the. That at six months, there's, they've been running through Sunnybrook, uh, quite a wonderful post GDM uh, workshop.
Nice for, for people. And that is really what we modeled this on in order to provide that opportunity to, for information and, and being able to empower you going forward.
Surabhi: Amazing. Um, and these workshops are they, do they have to be referred to sign up or Anyone can go to the website and they can sign themselves up in pregnancy, and it sounds like it's for pregnancy or postpartum.
Am I right
Dr. Fleming: for postpartum?
Surabhi: It's for postpartum. Okay. Postpartum. So postpartum, it's for people who have been diagnosed with one of those conditions in pregnancy and now what to do, you know, for themselves postpartum. Um, what is,
Karen Fungaren: so sorry. The, to sign up. It's, it's Heart Health matters.ca/work shop. Sign up.
Uh, we also have an Instagram, um, which [00:49:00] is Heart Health Matters Hub. And, uh, yes, it, it's, it's a virtual, uh, uh, workshop that's delivered. And the next one, that's the next two that are happening that we've planned for is June 26th, in the afternoon, two to four, and then September 25th. Same thing in the afternoon, two to four over Zoom.
Surabhi: Amazing. It's so convenient. So people can attend this. They don't have to, you know, come in person and they're still getting all that same amazing information.
Karen Fungaren: So that was actually one of the things that we learned from the gestational diabetes group postpartum, was that, um, actually their partners was also able to come.
Yeah. Uh, which helps with kind of that, you know, when you're six months postpartum or even we have people that join four months or seven, eight months postpartum, you're still could be a little bit sleep deprived. You know, you don't hear two people in the, in the room listening to information can be a lot more helpful than just one.
Um, and then the access. Uh, I mean initially we, it was because of [00:50:00] COVID that we switched to virtual, but it just meant that, uh, often a little bit more moms could attend. Um, yeah. You know, so it was really helpful. And one thing to sort of speak to the mental health aspect too is, um, the mom groups or parental groups that are available in the community are really important and helpful for that networking.
For information sharing and just for support. So things like early on, there's more private ones that, um, are fee-based. Um, but early on is, is one that I really try and get people to go to. And it's, it's, it's, I loved early on,
Surabhi: I went, went by with my first, my second was born in the pandemic, so nothing was open of course, but um.
Yeah, super, super helpful. You know, the isolation is very draining because especially if you're a social person and you're used to being around people, even though your baby is a person, they're not necessarily talking to you and communicating in the same way you're expecting. And sometimes you're like, I just wanna be around [00:51:00] adults.
And so I love that you talk about that in terms of mental health and, um, you know, these groups, they would get us moving to. Sometimes I've, I've done many talks at early on. On physical activity and, you know, physical therapy, um, pain management, how to lift properly, all these simple things that you think are intuitive, but they're really not.
And for an exhausted new, new parent, it's just so helpful to provide this, this information. Um. So I'm grateful that this exists and I hope that it, you know, is something that, um, takes off and that people, I, I just think a lot of people don't know about it. So this is, you know, your first step is spreading the mission, you know, spreading, um, this information around.
One thing that we, uh, I meant to ask is what is help syndrome? 'cause that was another thing listed on your website. Um, is that something that falls within that 7% risk of hypertensive disorders? Um, and if so, what is it?
Dr. Fleming: So it is a, so [00:52:00] you don't, interestingly with that one, it falls into the same family. So it's within the hypertensive disorders of, of, of pregnancy.
However, it doesn't come with hypertension necessarily. So it is, uh, uh, cluster of, uh, of changes in, in blood work. So it is rare and, uh, rarer, but it is a significant, uh, complication.
Surabhi: Okay.
Dr. Fleming: Okay.
Surabhi: Something for people to be aware of, right, is that, that might also link, link in with this, but it doesn't necessarily mean high blood pressure.
Um, and one thing I, this is anecdotal, but magnesium, I have known patients to take magnesium to help manage their, um, blood pressure. And so. I don't know if there's any validity to this, but would that then bring down their blood pressure and make them seem like it's all normal when they're actually not?
[00:53:00] Would that mask an elevated blood pressure is taking supplements?
Dr. Fleming: To the best of my knowledge, I do not think that magnesium would mask, uh, someone's hypertension in this. Okay. In this, in this setting of pregnancy.
Surabhi: Okay. Good. That's good to know. This just I've had. I heard of this a couple times and I was like, I dunno if magnesium alone is gonna do anything major.
But I also know that, um. Yeah, I
Karen Fungaren: just was curious 'cause and I, I think part of the aspect is like, how much of these supplements are we taking? Like is it, you know, factoring in often like the bioavailability. That's why those doses are often a little bit higher. That said, we can get. Many of these nutrients from food.
And it is a, a factor of looking at, are you one of those populations that have a higher risk because you don't eat a lot of foods with magnesium or calcium or iron, and that's when the supplement is really [00:54:00] important. Um, so of course I'm biased as a dietician, so if you have access to dieticians, they're good to talk to even once in your lifetime because it might help you understand some areas that you need to just be aware of.
Surabhi: In Ontario, how do, how does somebody go about working with a dietician? Is that something that, again, is needs to be referred to or is it. Direct access.
Karen Fungaren: Um, so if you're part of a family health team, uh, where your family doctor works in a fit or a family health team, you should normally have access to a dietician.
Uh, same idea with the CHC. So the, uh, community health centers, there's often dieticians there, there are dieticians in the diabetes clinics, diabetes prevention programs, uh, diabetes education centers. They may not specifically look at a post. Uh. Hypertensive disorder in pregnancy, type of, uh, look, but you know, just know that that's somewhere that you can find somebody.
And then, um, ultimately it is private practice. Uh, typically [00:55:00] people cannot access the dietician in a family health team unless they're a patient of that family practice, of that family health team.
Surabhi: That makes sense. Um,
Karen Fungaren: correct. But, um, again, many of us. Host sessions and information classes that are geared towards hypertension or cardiovascular risk that is open to the public.
So for example, at Sunnybrook, I have that opened up for anybody, even if you're not part of the family practice. But I don't provide the individual counseling or the, the kind of one-on-one session.
Surabhi: Yeah. Um,
Karen Fungaren: and then dieticians are not OH covered, so, but they may be covered through your in health insurance plan if you're seeing somebody privately.
Surabhi: Yeah. Similar to physiotherapy, right? It's if exactly many people have insurance for it, but, um, it's rare that it's ohip covered in Ontario
Karen Fungaren: and that's part of the, the discussion around primary care teams, right? Yeah. I know we're in the spotlight in primary care most recently in Ontario at least, so I can speak to that, but it's so helpful and [00:56:00] important that we are looking at all areas of care because I think.
It's not enough for one person to take on all the pressures, which is the family doctor or the nurse practitioner. Yeah. Things get missed not because of their fault, but because there's so many things happening. Yeah. Um, with one person, but also so many patients. So
Surabhi: yeah. And it's not necessarily their area of expertise to touch on every single aspect of the person's health.
And I think that's where the team collaborative approach is really, um, beneficial. 'cause so often, you know, even with. I can speak to exercise. People are told you should exercise, but knowing that they should and actually being able to do it, knowing exactly how to take that step to getting more movement, especially if they have pain or any symptoms, it's very tricky and that's almost always gonna be a barrier.
Um, or if they're stressed, overwhelmed, it's like, how do I actually get movement in, you know? Uh, people are often like, I'll wait till I lose weight. I'll wait till I'm less busy. I'll wait till I'm less stressed, but. We need to still move [00:57:00] through that and it can actually help with all those things. 'cause movement helps with mental health, physical health, pain, um, all the things.
So, um, I can definitely see that, you know, similar, similar thing happening with the nutrition, um, and a variety of different aspects of healthcare. So, um, thank you Dr. Fleming. And, um, thank you Karen for your time and your expertise. Is there anything else that we've missed today in our conversation that you would like to share?
Um, if so, please do.
Dr. Fleming: I think if I could ask you to take one thing away from the, the podcast is that remember to tell your healthcare provider what happened in pregnancy so that you can work together for future health.
Surabhi: I love that. I don't remember going back and telling my primary care provider anything.
I mean, there wasn't much to tell, but I don't really remember that being a, a conversation. So, um, I think being [00:58:00] intentional and planning to tell your doctor even if they don't ask about it, would be, um, would be a really good take home message so that they're up to date. Uh. On what's been happening, you know, on your health, on the side of your health.
Um, I will share all the links. So Heart Health Matters Hub is Instagram, heart health matters.ca is the website, uh, where you can sign up for the workshop. I'll share the link to sign up for the, the workshop as well. Um, and if you have any questions at all, I will share, you know, where you can connect with them so that, um, you can find out more.
